Report sounds hospital alarm as number of surgical mishaps in Tasmania rises

There were 115 medication errors at the Royal Hobart Hospital last financial year. Picture: Leigh Winburn Source: Mercury

THE number of surgical and medical mishaps in Tasmanian hospitals, such as foreign objects being retained in the body after operations, is rising.

In the last financial year at the Royal Hobart Hospital, there was a case of surgery on the wrong body part, three incidents where an unintended foreign object was retained after surgery and another case of an unexpected death in the operating theatre.

There were also 115 "adverse events" related to medication, including duplication of dosage, wrong dosages and even several cases where medication was given to the wrong patient.

There were also 55 medication errors at the Launceston General Hospital, the Department of Health and Human Services quarterly progress reports show.

The LGH also reported 149 surgical site infections and 270 other adverse events, including five accidental puncture or lacerations in procedures, and one post-procedural kidney failure.

The reports show the numbers of surgical episodes with one or more adverse event are slowly rising.

The first reporting of these was in the January-March quarter of 2012 when there were 216 adverse events across all public hospitals.

For the quarter to June 30 last year, there were 267 such cases.

The most recent report shows there were 307 adverse events in the three months ending September 30 last year.

Australian Nursing Federation state secretary Neroli Ellis said a number of factors could be causing the rise.

"Increased workload is a major contributing factor with increased demand on our hospitals and major hospitals are often over 100 per cent occupancy which is well above the 85 per cent agreed benchmark for safe patient care. This has occurred as a direct result of the budget cuts," Ms Ellis said.

"Increased workload and pressures have led to ongoing fatigue of all hospital staff with no fatigue management strategy implemented."

She said there may have been under-reporting at RHH for surgical infections and adverse events, as its stats seemed disproportionately low.

Australian Medical Association state president John Davis said any surgical episode was regrettable.

"The only thing I can think to put it down to is when you have budget cuts and staffing cuts and higher occupancy rates in our hospitals, everyone is working in a more stressful situation and that is when mistakes are more likely to happen," Dr Davis said.

Opposition health spokesman Jeremy Rockliff said hospital staff were under too much strain.

"When you cut the number of doctors and nurses and close hundreds of hospital beds, it places enormous pressure on the system and health professionals," Mr Rockliff said.

"[The Liberals] will inject $76 million into frontline health so that we can employ more doctors and nurses, open more beds, get the elective surgery waiting lists down and take the pressure off."

DHHS service quality and improvement director Grant Phelps said his unit was working with each health organisation to introduce the new safety reporting and learning system to "bring Tasmania into line with other jurisdictions across the country".

"The SRLS simplifies incident reporting and will provide accurate and comprehensive data to help THOs develop local approaches to reducing patient risk," Dr Phelps said.

"The new system is due to be rolled out in the first half of this year and will strongly support the healthcare system deliver safe and high-quality care into the future.

"The number of surgical episodes flagged by hospitals as possibly having an adverse effect fluctuates significantly from quarter to quarter at both an individual hospital and statewide level.

"Hospitals have their own approaches to understanding clinical care.

"The apparent small increase in the most recent quarter reported is within the typical range experienced previously at each hospital, and most likely a reflection of the increased elective surgery activity in recent months."

Alan Sandford, executive director of medical services for THO-South, said there were inherent risks of adverse events occurring in all healthcare.

"THO-South is, however, fully committed to constantly improving our quality and safety procedures and we have a number of measures in place to achieve this."

Comments on this story

Tania Mrzyk of Granton Posted at 2:28 PM January 14, 2014

Just while there is comment's about the Hospital's at the moment, I and like many others believe that even unemployed people should be contributing at least a sum
of say $100 per financial year towards the Royal Hobart Hospital, as this would help enormously . Why hasn't the Government done this as yet, I know if i was in that position, and know that one day like in the past, have to use it, then I don't mind paying.

Joc May of Hobart Posted at 10:53 AM January 09, 2014

This report is alarming, but it would be good to get some context - it details the stats for all the cases that went wrong, but how many were successful? For all the reader knows these numbers are a low percentage, it's hard to tell without all the information.

nick jones of lindisfarne Posted at 7:44 AM January 09, 2014

ryan smith - do some research for yourself. here's an article that appeared in Forbes magazine, discussing a study that appeared in the American Journal of Patient Safety - http://www.forbes.com/sites/leahbinder/2013/09/23/stunning-news-on-preventable-deaths-in-hospitals/
or you could of course google it for yourself.
All the stats for medication expenditure is available on the PBS website for you to look at, but here's an article which breaks it down much easier for you - http://www.pillarsofmodernman.com/obesity-how-much-is-it-weighing-down-our-healthcare-system/
in 2010-11 (financial year) there were 22.27 million presciptions for cholesterol lowering drugs, but our population in only 22.3 million!
and Sum yung Gai - 3 out of 4 people make up 75% of the population!

Lee Smith of Bohol, Philippines Posted at 11:12 PM January 08, 2014

So what, at least the choo choo train on the West Coast is up and running again.

Sum yung Gai of Launceston Posted at 11:01 PM January 08, 2014

Using dodgy statistics to persuade others into believing your point of view is used quite often. 87% of people of Tasmanians know that!

Ben Dune of Moonah Posted at 10:55 PM January 08, 2014

@ Ryan Smith of Hobart
Posted at 3:52 PM Today hahahaha nice one!

Mike England of Gretna Posted at 8:07 PM January 08, 2014

And more errors and wastage yet to come in the health system. Stay tuned